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Winter 12-16-2016

Fall Prevention in Acute Psychiatric PatientsJeannette DeanoUniversity of San Francisco, msdeano@gmail.com

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Recommended CitationDeano, Jeannette, "Fall Prevention in Acute Psychiatric Patients" (2016). Master's Projects. 479.http://repository.usfca.edu/capstone/479

Running Head: FALL PREVENTION IN ACUTE PSYCHIATRIC 1

Fall Prevention in Acute Psychiatric Patients

Jeannette Deano

University of San Francisco

FALL PREVENTION IN ACUTE PSYCHIATRIC PATIENTS

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Abstract

Patient falls have been an issue in hospital settings for many years. Patient falls not only

lead to increased costs for the hospital, but affects the safety and care for patients. Many studies

have assessed potential, contributable factors leading to falls, fall risk assessment tools, and fall

prevention interventions in different settings. However, there are limited studies done in inpatient

psychiatric settings. The acute-psychiatric unit at a large metropolitan hospital has seen an

increase in falls in the last year, yet current interventions have not addressed this issue.

The purpose of this project is to conduct an assessment of the unit’s current fall risk

assessment tool, interventions, and processes, while collecting and analyzing data of each fall

and patients who have fallen. The results will help determine potential causes to the increased

falls and help lead to solutions that can prevent future falls. Data was collected from patients’

chart reviews, Unusual Occurrence Reports, and RN interviews. Analysis of data show that many

patients were not identified as a fall risk at the time of his or her fall, while nurses on the unit had

differing definitions of the current falls protocol and policy on the unit.

The following interventions are recommended: education on the use of a fall risk

assessment tool that is appropriate for the acute-psychiatric population, instead of the current

Schmid Fall Risk Assessment Tool that is used for all departments of the hospital and training

for nurses on the unit to provide a clearer understanding of the unit’s falls protocol and policy

and fall prevention interventions.

FALL PREVENTION IN ACUTE PSYCHIATRIC PATIENTS

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Problem

In the hospital setting, falls continue to be the top adverse event (Spoelstra, Given, &

Given, 2012). Not only can falls lead to serious injuries, but also increases the costs for the

organization. Psychiatric inpatients who had recurrent falls had a significantly longer lengths of

hospital stay compared with other inpatient populations (Greene et al., 2001). Many studies on

acute inpatient psychiatric units have focused on behavioral management, patient safety, and on

the threat of harm to self or others including suicide. Fewer studies have focused on fall

prevention and the need for a different approach to fall prevention compared to other inpatient

hospital units.

In one of the psychiatric units (7B) of the large metropolitan hospital, an increase in falls

occurred in the past year. The hospital’s quality improvement team questions whether the

increase in falls are related to the improper use of the current, fall risk assessment tool, the lack

of validity of the assessment tool, or the lack of nursing interventions for patients who are

considered fall risks. Currently, 7B uses a standard fall risk assessment tool called the Schmid

Fall Risk Assessment Tool, which assesses the patient’s mobility, mentation, elimination

patterns, history of falls, and current medications. Questions arise whether a different assessment

tool that is more applicable to the psychiatric population is needed to appropriately determine

whether a patient is a fall risk.

Furthermore, we question whether interventions provided by staff is adequate and

whether staff are aware of interventions for patients who are fall risks. Nurses currently follow

interventions in the Nursing Plan of Care (NPOC) when a patient is considered a Falls Risk. The

intervention listed in the NPOC can be checked off, but may not be implemented appropriately.

FALL PREVENTION IN ACUTE PSYCHIATRIC PATIENTS

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Rationale

Literature Review

The literature review was conducted using CINHAL Complete database. Boolean

operators and MESH terms search criteria were used to expand and restrict the search. In

CINHAL’s advanced search, using the keywords “psychiatric AND fall prevention,” while

limiting it to reviews published in the last 10 years, 36 articles were retrieved. These included

primary studies, meta-analyses, retrospective analysis, and systematic reviews.

A fall is defined as a “an unplanned descent to the floor with or without injury to the

patient” (AHRQ, 2013). Different types of falls can occur in a psychiatric unit, including

environmental, physical, physiological, or intentional. Environmental falls include falls caused

by wet floors or unstable furniture. Physiological fall can include falls related to the patient’s

mobility, balance, gait problems, sensory impairment, disorientation, confusion, effects of

medication, substance use, orthostasis, or dizziness. Physical falls are falls related to the patient’s

use of assistive devices, ill-fitting shoes, or personal safety issues (Poster, Pelletier, & Kay,

1991). An intentional fall is when a patient intentionally descends to the floor and can occur as a

way of acting out or gaining attention (Staggs et al., 2015). According to the Agency for

Healthcare Research and Quality in 2013, between 700,000 and 1 million patients suffer a fall in

United States hospitals per year, with between 30 and 51 percent of falls result in an injury.

Studies on fall prevention in psychiatric units are limited compared to fall prevention

studies in other units. Studies have investigated the effectiveness of nursing fall risk assessment

tools, interventions that reduce fall rates or minimize the risk of falling, and common fall risk

factors in adult psychiatric patients. The combination of having proper assessment tools,

FALL PREVENTION IN ACUTE PSYCHIATRIC PATIENTS

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interventions, and awareness of risk factors seem to be the most successful in preventing falls for

psychiatric patients.

Abraham conducted a review of possible fall risk assessment tools in 2016 and reviewed

7 risk assessment tools to determine the best instrument for psychiatric inpatients, since proper

identification and precise assessment of individuals at risk are important components of fall

prevention programs. The study found that the Wilson Sims Fall Risk Assessment Tool and the

Edmonson Psychiatric Fall Risk Assessment Tool had the highest sensitivity and specificity

scores. Wilson Sims had a sensitivity score of 100% and a specificity score of 63%. Edmonson

had a sensitivity score of 63%. The major difference between the two tools is that the WSFRT

included a column for the clinical judgment of the nurse, which offers an important factor for

predicting a potential fall risk.

Quigley, Barnett, and Friedman studied psychiatric units of 5 hospitals in similar

metropolitan cities in 2014. An operational strategic plan to address each falls prevention

program element and improve program infrastructure and capacity was conducted using expert

faculty lectures, coaching, and mentoring. Three projects were implemented simultaneously

including a fall prevention program customized for inpatient psychiatry, a unit peer leader

program for falls, and a customization of hip protectors and floor mats in psychiatry settings.

Results were analyzed using quantitative and qualitative methods. Data analysis showed that

improvements were evident in fall injury risk assessment and discharge education, with the

largest positive change reported for environmental safety to reduce the severity of injury.

Quantitative results showed the average fall rates decreased from 16% to 9%. However, the

average fall related injury rates remained the same and average percentage falls with serious

injury increased.

FALL PREVENTION IN ACUTE PSYCHIATRIC PATIENTS

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A systematic review conducted by Xu et al. included eleven studies with three before-

and-after studies, four descriptive studies, two case control studies and two cohort studies (2012).

One before-and-after exploratory study by Irwin between 1996 to 1997 implemented a modified

fall risk assessment tool that was revised using literature findings and retrospective chart review

of fall and non-fall patients, in addition to introducing a fall protocol. The study’s results showed

that in 1997, 85% of patients who fell and 28% of non-fallers obtained a positive score,

compared to 53% and 57% of patients respectively in 1996. These results suggest that the

modified fall risk assessment tool could be more predictive of falls in psychiatric patients.

Three of the studies included in the systematic review all implemented fall prevention

programs by primarily including observation by nursing staff, ambulating exercises for patients,

physiotherapist and occupational therapist involvement, modification of extrinsic factors,

education for both patients and nursing staff, medication profile review by doctors or

pharmacists, and consistent monitoring of changes in patients’ standing and lying blood pressure

(Xu et al., 2012). Murdock et al. implemented a mandatory blood pressure taking policy in order

for staff to be aware of side effects of psychotropic medications, allow stricter documentation of

each patient’s blood pressure and review of medications upon assessment of blood pressure after

falls (1998). The study found that the rate of falls increased after the intervention, but the rate of

repeated falls decreased from 50.9% to 32.5%. The authors attributed the decrease in repeat falls

from adjustments of medications related to postural hypotension and increased awareness of this

problem, but probably to a lesser extent due to an increase in first fall. Yates and Tart studied

the effects of an intervention that included a new type of nonskid slipper sock footwear, a Fall

Prevention and Awareness Education Brochure for patients upon their admission, and a medical

FALL PREVENTION IN ACUTE PSYCHIATRIC PATIENTS

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profile review by pharmacy and annual staff education (2010). After a two-year study, results

showed that fall rates decreased by 32% after including the new intervention.

Other hospitals in the bay area have implemented its own fall prevention interventions.

Stanford Hospital had implemented an intervention that included fall focused rounds for

bathroom assistance and patient teach back, post fall debriefings to adjust care plans and prevent

repeated falls, and medication monitoring and education of frequently used medications for

patients and staff (Varquez, 2009). Before the study started, a thorough assessment was done for

one year to determine characteristics of the psychiatric population and their relation to falls.

Results showed that repeat falls dropped to 0, while the falls rate remained the same.

The current data has shown the importance and effectiveness of having an assessment

tool that is appropriate to patient population. Standard assessment tools such as the Wilson Sims

Fall Risk Assessment Tool and the Edmonson Psychiatric Fall Risk Assessment Tool have

shown to be able to appropriately identify patients who are considered fall risks. Other studies

have assessed the unit’s specific population to make adjustments to the current assessment tool,

which has also lead to the development of a more effective assessment tool. Interventions for fall

risk patients have focused on the effects of taking a combination of psychotropic medications on

the risks of falls. Interventions that allow staff to monitor side effects of psychotropic

medications and provide more opportunities to adjust medications appropriately in response to

falls seem to be effective interventions to prevent repeat falls in the psychiatric population. A

combination of interventions that addresses environmental, physical, and physiological falls can

be effective in decreasing overall falls.

Cost Analysis

FALL PREVENTION IN ACUTE PSYCHIATRIC PATIENTS

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According to the Centers of Disease Control and Prevention (2016), costs for falls to

Medicare alone totaled over $31 billion in the United States. Adjusted to 2010 dollars, one fall

without serious injury costs hospitals an additional $3,500, while patients with more than 2 falls

without serious injury have increased costs of $16,500. Falls with serious injury are the costliest

with additional costs to hospitals of $27,000 (Wu, Keeler, Rubenstein, Maglione, & Shekelle,

2010).

On 7B, a reported 45 falls occurred amongst 31 patients within the last fiscal year. Six of

the thirty-one patients had fallen repeatedly on the unit, with 3 patients who fell more than twice.

With 3 patients who have more than 2 falls, the costs of falls without serious injuries is $49,500.

With thirty-one patients who have fallen without injuries, the costs would be $108,500. If all

thirty-one patients had fallen with serious injuries, the potential costs would be $837,000 in just

one year.

Through proposed interventions described in later sections, these costs can be reduced.

The costs of implementing a new assessment tool and providing training and education to staff

regarding fall prevention interventions and protocol is $17,889.00, assuming that the amount of

training and education will not exceed 300 hours and the standard Wilson Sims Fall Risk

Assessment Tool is implemented as a replacement to the Schmid Fall Risk Assessment Tool.

The amount is just a small fraction of what can potentially be saved from patient falls. Assuming

that none of the falls led to any serious injuries this last fiscal year, the proposed interventions

can save up to $158,000 per year. Even more can be saved if injuries were associated with any

one of these falls.

Project Overview and Methodology

Data Source

FALL PREVENTION IN ACUTE PSYCHIATRIC PATIENTS

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Data was obtained from patients’ chart reviews, Unusual Occurrence Reports and

interviews of Registered Nurses in 7B. Patients who have fallen during the fiscal year were

identified by data from a member of the quality improvement team, while Unusual Occurrence

Reports were obtained by a member of the falls committee for the psychiatric unit. After

identifying the patient’s name and date of fall during the last fiscal year, charts were requested

from the medical records department. Records were delivered after two days, which were then

reviewed and data was transferred onto an excel sheet that included twenty different,

characteristics for each patient. Each patient was assigned a numerical value to maintain

confidentiality. Data for each patient included gender, age, presence of bone disease or

osteoporosis, coagulopathy, recent surgeries, primary diagnosis, psychological diagnosis,

comorbidities, medications, current drug or alcohol use, history of drug or alcohol use, housing

situation, date of fall, time of fall, identification of fall risk prior to fall, Schmid score at

admission, repeated fall on unit, type of fall, fall prevention plan, and witnessed or non-

witnessed fall. Data for the latest fall was recorded for patients who had repeated falls on the

unit.

Fourteen interviews of Registered Nurses on the unit were conducted. Interviews were

conducted during AM shifts (7:00am-3:30pm) and PM shifts (3:00pm-11:30pm). Experience of

nurses ranged from five months to twelve years. Initial interviews contained six questions, but

after one initial session, two additional questions were asked (See Appendix A). Interviews were

conducted to determine the current knowledge of nurses on the unit in relation to fall risk

assessment and fall prevention interventions in 7B. Interviews were focused on the use of the

Schmid Fall Risk Assessment Tool, the current Falls protocol, and interventions when a patient

is labeled as a fall risk.

FALL PREVENTION IN ACUTE PSYCHIATRIC PATIENTS

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Expected Outcomes

The purpose of the project was to obtain detailed information about patient

demographics, registered nurses, unit processes, and current fall risk assessment and fall

prevention tools to determine potential reasons for increase of falls on the unit. Information is

gathered in order to assess and identify possible issues that lead to falls. These issues can be

related to a possible lack of knowledge of registered nurses regarding assessing fall risk patients

and activating appropriate post falls interventions. The project also looks at the validity and

reliability of the current Schmid Fall Risk Assessment Tool to determine whether it is

appropriate for 7B’s patient population. Lastly, the project aims to assess patient demographics

and descriptions of the incident to develop a clear understanding of additional factors that could

have caused the fall.

After analyzing data, recommended interventions can be made to prevent future falls.

Depending on the results of the data, a new fall risk assessment tool can be recommended that is

more appropriate for assessing the patient population. If nurses are utilizing the current, Schmid

Fall Risk Assessment Tool incorrectly or not following appropriate protocols, further education

or training can be provided. If current fall precaution practices are inadequate, new interventions

should be discussed in order to address possible reasons of falls developed from data gathered by

this project.

Nursing Relevance

It is important to promote patient safety as a nurse. Understanding the reasons for falls on

the unit can allow nurses to assess and monitor patients with a gained awareness of contributable

factors for falls. Being aware of these factors can lead nurses to more accurately identify patients

who are a fall risk at admission and recognize signs early enough to prevent a potential fall. The

FALL PREVENTION IN ACUTE PSYCHIATRIC PATIENTS

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nurse’s role as an educator becomes important, as he or she can educate patients and other staff

members on how to prevent future falls. In order to create improvements for patient care, the

nurse’s skills as a leader and care manager is important in taking the initiative to find the cause

of the issue and involve others in finding solutions to the problem.

The vision of this hospital is to “advance community wellness by aligning care,

discovery, and education,” while its values and commitments include clinical quality, health

equity, safety and accountability. 7B can meet this vision as nurses continue to obtain and

analyze data to improve care and provide clinical quality care. Nurses can promote safety

through education and providing appropriate care through new knowledge gained from data. As

a nurse, he or she is dedicated to the safety of patients and have a responsibility to ensure their

safety through the values of the organization.

Summary Report

Root Cause Analysis

After gathering information from chart reviews, Unusual Occurrence reports and

interviews with Registered Nurses on 7B, data suggests that there is a lack of knowledge

amongst nursing staff regarding falls protocol and poor fall risk assessments that led to missed

identifications of fall risk patients. Although, registered nurses were aware of how to assess for

different characteristics listed on the Schmid Fall Risk Assessment Tool, many patients who

have fallen received a score that did not consider the patient as a fall risk at admission, which can

suggest the possibility of the unit not having an appropriate assessment tool for the psychiatric

patient population.

Furthermore, many nurses were unclear of what the exact Falls Protocol on the unit

entailed. Nurses had differing answers with some who were unaware that a protocol existed.

FALL PREVENTION IN ACUTE PSYCHIATRIC PATIENTS

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With nurses unsure of actions to take after a fall occurs, preventative measures and appropriate

patient care cannot be provided optimally. Preventative measures include appropriately

documenting and activating the Fall Risk section in the patient’s NPOC and assessing side

effects from taking a combination psychotropic medications. This suggests that further education

is needed for nurses to have a clear understanding of what actions should be taken after a fall to

prevent a repeat fall and provide care for a patient to address possible injuries from the fall.

Redesign of Process

Initially, a thorough assessment and an intervention was to be implemented to address

issues identified from data. However, due to time constraints, only an assessment was conducted.

Additional characteristics were included into the assessment including orthostatic

hypotension/drowsiness side effects of medications and types of fall prevention interventions. An

additional behavioral type of fall was added to describe falls involved in aggression towards staff

or self, leading to the fall. Intentional type of fall was not used. Interviews with patients were not

completed due to the risk of not obtaining credible responses as a result of the patient’s

psychiatric diagnosis and altered mental status.

Interviews and observations of fall risk assessments with nurses were to be conducted, as

the fall risk assessment was done for a patient during each shift. However, the fall risk

assessment was only done during the initial patient admission into the unit so planning

observations was not possible. Interviews were planned at three different shifts and days.

Initially, six questions were included in the interview, but two additional questions were then

added to obtain nurses’ opinions on the unit’s fall protocol’s adequacy and recommendations for

improving the current protocol.

Implementation

FALL PREVENTION IN ACUTE PSYCHIATRIC PATIENTS

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Due to the uncontrollable time constraints of this project, interventions were not

implemented, but recommendations are proposed for future projects. After analyzing the data, it

is recommended that a pilot study of at least one of the two recommended interventions is started

in the near future. Since many patients who have fallen received a score that determined him or

her as a non-fall risk during the initial admission, it can be suggested that a different assessment

tool should be used to provide a more accurate assessment. The Wilson Sims Fall Risk

Assessment Tool is recommended, because it has produced results with high sensitivity and

specificity for the psychiatric population, while allowing nurses to add his or her own clinical

judgment. The nurse’s clinical judgment can have a significant impact on the assessment,

especially if the nurse has many years of experience with the psychiatric population. The new

assessment tool would replace the Schmid Fall Risk Assessment at admission to evaluate the

effects on patient falls for a duration of one year.

Another recommendation is to provide more education and training for nursing staff

regarding the current Falls Protocol. Data from interviews show that nurses are unsure about

what the Falls Protocol entails. Further training and education can make it clear for nurses of

what exact actions should be taken in response to a fall and when a patient is considered fall risk.

Instructions to completing Unusual Occurrence reports should also be included in order to

provide detailed data on each fall that can be used to create a more accurate root cause analysis.

This can be provided for at least 30 hours per week for a duration of one to two months. Four 30-

minute sessions would be done during each shift for 4 to 5 days/week or until every nurse

assigned to 7B is seen. Questions can be answered to provide clarity and nurses’ knowledge can

be re-assessed after training and education.

Results

FALL PREVENTION IN ACUTE PSYCHIATRIC PATIENTS

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Since no interventions were implemented for this project, results from data collection will

be described in this section. Data was recorded onto an excel sheet and was further analyzed (See

Appendix B). Results show that 17 of patients who fell were male, with 11 of patients who were

female. The average age was around 50 years old with a range from 22 years old to 69 years old.

No patients had a bone disease or Osteoporosis. Seven patients had coagulopathies, 19 patient

had no coagulopathies, and 2 were unknown. Three patients had recent surgeries, 1 had a history

of surgeries with unknown dates, and 24 had no recent surgeries. Eighteen patients were

diagnosed with Schizophrenia or Schizoaffective Disorder, 4 patients were diagnosed with

Bipolar disorder, 2 with Anxiety Disorder, 2 with Cognitive Deficits, 1 with Major Depression,

and 1 unknown. Twenty-eight patients were taking at least one psychotropic medication that has

a side effect of orthostatic hypotension or drowsiness and 3 patients had unknown medication

orders. Twenty-four patients had comorbidities, 2 patients had no comorbidities, and 2 were

unknown. Sixteen patients denied current drug use, 7 patients admitted to current drug use, and 5

were unknown. Fourteen patients had a history of drug use, 7 denied a history of drug use, and 7

had unknown histories. Sixteen patients were not identified as fall risks at the time of their fall, 8

patients were identified as fall risks at the time of their fall, and 4 had unknown identifications.

Sixteen patients received a Schmid score below 3, 5 patients received a score of 3 or above, and

7 patients had unknown scores. Ten patients were homeless, 14 patients were housed, and 4 had

unknown, housing situations.

Dates of falls ranged from July 1st, 2015 to September, 18, 2016 from the last fiscal year.

Ten falls occurred during NOC shifts, 12 falls occurred during AM shifts, 4 falls occurred during

PM shifts, and 2 were unknown. Twenty-one percent were repeat falls, 64.3% were not repeat

falls, and 14.3% were unknown. Five falls were determined to be behavioral, 4 falls were

FALL PREVENTION IN ACUTE PSYCHIATRIC PATIENTS

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medical/physiological, 12 falls were accidental, 2 were environmental, and 5 had unknown types.

Nineteen had a subsequent fall prevention plan, 2 had no fall prevention plan activated, and 7

were unknown. Interventions included in the fall prevention plan included post huddle, daily

assessment of falls status, providing assistive devices, establishing toileting routine, adding a

yellow star on chart, Kardex, and patient door, activating “Falls Precautions”, keeping bedside

area dry and clutter free, providing safe footwear, moving patient to room close to nursing

station, and adjusting medications. Thirty percent of the interventions from the fall prevention

plan included implementing “falls precautions” and 23.3% included assessing fall status daily.

“Falls Precautions” however, was not described so specific actions for this intervention is

unknown. Nine of the falls were not witnessed, 5 falls were witnessed, and 14 were unknown.

Responses of 7B Registered Nurses were recorded during the interview and subsequently

categorized and analyzed (See Appendix C). Nine nurses were interviewed during AM shifts and

5 nurses were interviewed during PM shifts. The first 4 questions were asked to find how

characteristics that can determine whether a patient is a fall risk are assessed. To assess

orientation and neurological status, 65% of nurses report that they ask the patient, 31.6% observe

the patient, and 5.3% will look at the chart or Kardex. Questions include asking person, place,

date, and situation. When assessing patient mobility, 47.6% observes the patient, 23.8% finds

data from chart or Kardex, 14.3% finds data in shift report, and 14.3% asks the patient. When

assessing elimination patterns, 50% asks the patient about his or her elimination patterns, 22.2%

observes the patient when toileting, 16.7% looks at the patient’s chart or Kardex, and 11.1%

obtains data from shift report. When assessing the patient’s history of falls, 54.2% looks at the

patient’s chart or Kardex, 29.2% asks the patient if he or she has fallen in the past, 12.5% will

gain information from shift report, and 4.2% will observe the patient.

FALL PREVENTION IN ACUTE PSYCHIATRIC PATIENTS

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Nurses were also asked about interventions for fall risk patients and the unit’s Falls

Protocol. Responses varied among all nurses. Responses for Fall Risk interventions include one

to one order for patient, closer observation, education for patients, notification of MD for Falls

Precautions order, documenting and notifying staff, clearing away clutter, wearing a band,

moving room close to nursing station, assessing medications and side effects, and providing non-

skid socks. One nurse was unsure about interventions for fall risk patients. Responses for the

meaning of Falls Protocol were similar to fall risk interventions, but with different proportions.

The most common response for what the nurse should do when a patient is considered a fall risk,

is to notify the MD to obtain a Falls Precautions order. When nurses were asked what it meant

when the Falls Protocol is activated, 28.6% of the nurses were unclear about it meant, while

28.6% of nurses state that it meant that the incident should be documented and staff should be

notified. When asked if he or she thought the falls policy and protocol was adequate, 6 thought it

was adequate, 2 thought it was inadequate, while one could not answer because she was not

aware that there was a Falls Policy and Protocol in place.

Evaluation

As stated previously, due to time constraints, an evaluation of the intervention was not

completed. To determine any improvement from using the new assessment tool for future

projects, data would be collected after a year to determine whether the number of falls decreased

or not. Furthermore, data would be collected to determine whether patients were correctly

labeled as a fall risk at admission and throughout the patient’s stay. To determine nurses’

knowledge after the in-service training, a post-test will be given to assess their understanding of

the unit’s fall risk protocol, how to complete more thorough UO reports, and fall risk

interventions.

FALL PREVENTION IN ACUTE PSYCHIATRIC PATIENTS

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Conclusion

This project has shown a bigger picture of the unit’s current approach to reduce falls,

which has its strengths and weaknesses. It was surprising to find that many of the patients who

have fallen were not identified as a fall risk on assessment, which prevented appropriate, fall

prevention interventions to be implemented. It was also surprising to see how the staff’s

approach to fall risk patients differed and some lacked knowledge about the current protocol and

policy. Conducting more interviews with the nursing staff could have provided a more accurate

picture of their overall view of the unit’s fall risk prevention practices. The majority of the time

was spent reviewing chart reviews and Unusual Occurrence Reports, transferring data onto an

excel sheet, and analyzing the data. With limited time, more interviews were not conducted.

Future efforts should involve more training for nursing staff to ensure that proper actions are

taken for patients who are fall risks and are aligned with the unit’s fall risk protocol and policy.

Also, it is recommended to utilize a fall risk assessment tool that can better identify those who

are fall risks at admission.

It is also important to add that it was difficult to determine the actual type of fall when

reviewing Unusual Occurrence reports. The reports had little information regarding the fall or the

patient. With the provided description, some falls that were labeled accidental, can potentially be

physiological, as some reports contained statements such as “sitting in shower chair and fell to

the floor,” “fell during urination,” and “pt was walking and started to run, so he tripped and fell.”

Higher quality data could have been retrieved with more available UO reports and better

descriptions of factors surrounding the fall. Therefore, additional training on completing UO

reports was recommended so that further interventions that address the common type or types of

falls can be addressed, as well.

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Xu, C., Tan, X. N., Shi, S.L., Yip, W. T., Tan, J. M., Premarani, K., et al. (2012).

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psychiatric patients: A systematic review. JBI Library of Systematic Reviews, 10(9), 513-

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Yates, K. & Tart, R.C. (2010) Acute care patient falls evaluation of a revised fall prevention

program following comparative analysis of psychiatric and medical patient falls. Applied

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Appendix A

RN Interview Questions

1. How do you assess orientation and neuro status?

2. How do you identify the level of patient mobility?

3. How do you identify patient elimination patterns?

4. How do you come to know the patient’s history of previous falls?

5. When you identify a patient who is a fall risk, what do you do next?

6. If one says to activate Falls Protocol, what does that mean?

7. Do you think the unit’s falls policy and protocol is adequate for your unit? If not, do you have

any recommendations?

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Appendix B

Patient Demographics, Falls, and Interventions

Chart Review/UO Reports Data - Patient Demographics

Name Gender Age Bone disease/osteoporosisCoagulopathy: Low dose aspirin, coumadinRecent Sx Primary Dx/Psych DxComorbidities Medications Orthostatic Hypotension/Drowsiness Side EffectsCurrent Drug/Alcohol useHx Drug/Alcohol UseHoused or Homeless

2 M 48 unknown unknown no Cognitive Deficit Depression, Seizure Disorder, Impusle Control Disorder, Hx of TBIunknown unknown no no Homeless

3 F 67 no yes no Schizoaffective disorderHTN, NIDDM, NSD Aripiprazole, Aspirin 81mg, Metformin, Metoprolol Yes no no Housed

4 F 66 no no unknown Bipolar affective disorderDM II, Emphysema, Siatica, AsthmaArtovastatin, Duloxetine, Insulin-human glargine, metformin, risperidoneYes no no Housed

5 F 62 no no no Cognitive Deficits HTN, Cirrhosis, CVA, hx of multiple TBIs, HemiplegiaAmlodipine, Baclofen, Ferrous Sulfate, Mirtazapine, nitrofurantoin monohyd/m-cryst, PantoprazoleYes no yes Homeless

6 M 58 no unknown no unknown unknown Unknown Unknown unknown unknown Homeless

7 F 60 no yes no Severe Anxiey MDD, Psychosis Ferrous sulfate, Lisinopril, Ondasteron HCL, Zoloft, Seroquel, Klonopin, Yes unknown unknown unknown

8 M 28 no no no Schizoaffective disorder, bipolar typeNone Acetaminophen, Bisacodyl supp, Clonazepam, Divalproex Sodium ER, Olanzapine, Pneumovax, Flu VacYes yes yes Housed

9 M 68 no yes no Schizoaffective DisorderCOPD, Pneumonia, CAD, Heep C, BPH, PSA, HTNacetaminophin, albuterol, aspirin, atorvastatin, bechlmethasone diphenhydramine, fentanyl, finasteride, Heparin sidoum, ipratripium bromide, ertapenem, levothyroxine, kflex, pantoprazole, senna, Yes no yes Housed

10 M 60 no yes no Schizoaffective disorder, bipolar typeHTN, hypothyroidism, COPD, hyperlipidemia Aspirin 81 mg, clonazepam, Divalproex, Invega Sustenna, Propranolol, Quatiapine, Synthroid Yes no yes Housed

11 F 54 no no no Schizoaffective disorder, mixed typeDM, HTN, L sided Weakness, Hx of past +TBUnknown Unknown no no Housed

12 F 36 no no no Bipolar Disorder Personality Disorder (Unspecified) olanzapine, Bacitracin, Yes no yes Housed

13 M 57 no no no Catatonic SchizophreniaHTN, DM acetaminphien, bisacodyl, enoxaparin, lorazepam, haloperidol, diphenhydramine Yes no unknown Housed

14 M 49 no no no Schizoaffective disorderHuntingtons ChoreaKlonopin, VPA, Haldol, Zyprexa, Metformin, Amlodipine, MetamucilYes unknown unknown Housed

15 F 30 no no no Schozoaffective disorderbipolar disorder Haldol, Acetaminophen, Diphenhydramine, Mag hydroxide, Bisacodyl Yes yes yes Homeless

16 M 43 no yes no Schizophrenia Seizure DisorderClozapine, Divalproex, Docusate Sodiu, Phenytoin Sodium, Senna, Albuterol, BisacodylYes unknown unknown Housed

17 M 69 no no no Schizophrenia epleptic, ventral hernia, COPD, anemia, dyslipidemia zoloft, klonopin, geodon, depakote, benadryl, Haldol, ativan, Yes no unknown Homeless

18 M 33 no no no Schizophremia chornic paranoid type (SCPT)Anxiety, depressionativan, trazodone, cogentin, Yes No Yes Homeless

20 M 45 no no no MDD, ANXIETY DISORDERHTN, TACHYCARDIA, NARCISSISTIC PERSONALITY DISORDER ZOLOFT, KLONOPIN, TRAZODONE, ATIVAN, HYDROXYZINE, LISINOPRIL, METOPROLOLYes yes yes Housed

21 F 52 no no no Schizophrenia PTSD, SAD, depresssed, HTN, DMPerphenazine, Venlafaxine, Buspirone, Proazoin, MVIYes no no Homeless

22 F 39 no no no Schizoaffective disorder, bipolar typehyperthyroidism Depakote, Clonazepam, Methimazole, Olanzapine, Haldol PRN, Lorazepam PRN Yes unknown unknown unknown

23 F 56 no Yes no schizophrenia Borderline PD, leukopemia, DM, Thyroid disorderbenztropine, cholecalciferol, docustate sodium, ferrous sulfate, gabapentin, haloperidol, levothyroxine, lorazepam, metforminYes unknown no Housed

24 F 44 no no yes Unspecified Schizophrenia Spectrum with other psychotic DOChurg Strauss Vasculitis, Untreated Breast CA per pt statementAlbuterol, Baclofen, Beclomethasone Dipropionate HFA, Ibuprofen, Ipratroprium, Montelukast, Olanzapine Yes yes yes Homeless

25 M 61 no no no MDD (Bipolar) HTN, DM 2, DepressionLovenox, Metroprolol & Lisinopril, insulinYes no yes Housed

27 M 22 no no yes Bipolar Disorder (NOS)none Perphenazine, Lithium, Senna, Oxycodone, seroquel, benadryl, klonopinYes yes yes homeless

28 M 56 no no no Schizophrenia Diabetes Clonazepam, OlanzapineYes yes yes unknown

29 M 31 no yes no Schizoprenia substance use disorder, seizure vs pseudo-seizuire disorderDepakote, Clonazepam, Methimazole, Olanzapine, Haldol PRN, Lorazepam PRN Yes unknown yes unknown

30 M 66 no no yes Depression, psychosis, PSA on MMTHx of sz d/o, Afib, CVA, COPD, CHF, HCV +Mirtazapine, Methadone, Benadryl Lomotil PRN, Mag-Al Plus ES PRN, MVIYes yes yes Homeless

31 M 52 no no no Schizoaffective Disorder, bipolar typeunknown Invega Sustenna, Lithium, Depakote, Klonopin Yes no no Housed

Chart Review/UO Reports Data - Falls and Interventions

Name Date of Fall Time of Fall Fall Risk IdentifiedSchmid Score Repeat Fall on unit (nth)Type of Fall 1=Physical/Accidental 2=Physiological/Medical 3=Behavioral 4=EnvironmentalFall Prevention Plan/Interventions Viewed (0=No, 1=Yes

2 9/18/16 1040 yes 6 yes (4th) 3 Post huddle unknown Fall Prevention Plan/Interventions Count

3 6/18/16 noc no unknown no unknown Assess falls status daily, falls precautions 0 Post Huddle 1

4 6/7/16 550 yes 3 no 1 unknown 0 Assess Fall Status Daily 10

5 6/29/16 unknown no unknown yes (7th) 1 unknown unknown Falls Precautions 13

6 5/19/16 unknown unknown unknown unknown unknown unknown unknown Establish Toileting Routine 5

7 5/8/16 1455 no unknown unknown 1 unknown unknown Keep bedside area dry and clutter free 4

8 3/27/16 2000 no 2 no 1 unknown 1 Room close to Nx station 1

9 3/16/16 2355 yes unknown yes (2nd) 3 Falls Precautions 1 Assistive Device 2

10 3/14/16 120 no 2 no 1 no 0 1:1 4

11 2/18/16 1130 no 2 no 3 Assess falls status daily, establish toileting routine, falls precautions, keep bedside area dry ad clutter free, room close to nx stationunknown Fall Protocol Implemented 1

12 2/15/16 430 no 1 no 2 unknown 1 Provide safe foot wear 1

13 2/2/16 1215 yes 5 yes (2nd) 1 Assesss falls status daily, establish toileting routine, falls precatuions, keep bedside area dry and clutter free (no notes of goals met) 1 Medication/Side Effects Assessment 1

14 12/27/15 1150 yes unknown unknown 1 Assesss falls status daily, establish toileting routine, falls precatuions, keep bedside area dry and clutter free (no notes of goals met) 0

15 12/17/15 1900 no 0 no 3 Assess fall status daily, falls precautions 0

16 11/17/15 10 no 2 no 4 Assess falls status daily, falls precautions 0

17 11/11/15 1340 Yes 6 yes (6th) 1 Assess falls status daily, assistive device (w/c), establish toileting routine, fall precaution, 1 on 11

18 10/12/15 1032 no 0 no 4 Falls Precautions unknown

19 9/25/15 30 no 1 no 2 Falls precautions, assess falls status daily (no notes on what they did for fall precuations) unknown

20 9/5/16 1430 no 2 yes (2nd) 1 Montior pt for dizziness and vital signs for symptoms fo orthostasis, counsel pt and reaffirm getting up slowly to decrease risk fo falls, reevaluate use of propranolol in this pt0

21 9/12/15 45 Unknown unknown unknown unknown unknown unknown

22 9/11/15 910 no 1 no 1 Falls protocol implemented 0

23 9/7/15 119 no 2 no unknown no 0

24 8/26/15 2220 no 1 no 2 1:1 unknown

25 08/16/15 1530 no 1 no 1 1:1 unknown

26 8/11/15 40 no 1 no unknown Falls precautions unknown

27 7/23/15 1100 no 2 no 3 1:1 sitter, precautions per MD order, frequent contacts w/staffunknown

28 7/4/2015 1330 yes 3 no 2 Assess falls status daily, assitive device, establish toileting routine, falls precautions, keep bedside area dry and clutter free unknown

29 7/1/2015 1600 yes 2 no 1 Assess falls status daily, falls precautions unknown

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Appendix C

7B Nurse Interviews

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